Discharge and Transfer from NUH Policy

Transcription

1 Discharge and Transfer from NUH Policy Reference CL/CGP/036 Approving Body Trust Board Date Approved 28 May 2015 Implementation Date 28 May 2015 Supersedes Version 4 (February 2012) Consultation Clinical Leads Medical Director NUH Discharge project leads Matrons Infection Prevention and Control Team Directors Group Integrated Discharge Team Transport Manager Safeguarding lead Date of Completion of Equality May 2015 Impact Assessment Date of Completion of We Are May 2015 Here Assessment Date of Environment Impact Not applicable Assessment (if applicable) Target Audience All staff involved in Discharge and Transfer Planning for patients. Supporting Documents/References Refer to References Review Date March 2017 Lead Executive Chief Nurse Fiona Branch Author/Lead Manager Better for You Discharge Team Further Guidance/Information Integrated Discharge Team June 2015 Page 1 of 44

2 CONTENTS Paragraph Title Page 1. Introduction 4 2. Background 4 3. Policy Scope 5 4. Policy Statement 5 5. Principles 6 6. Enacting the Principles 8 7. Responsibilities 9 8. Nurse facilitated discharge Common arrangements for discharge and transfer Transportation (including bariatric and DNACPR patients) Dressings / care products and medicines to take out Equipment to take out Medical Certificates Medical Device Removal Specialist Nurse Involvement Outpatient Appointments NHS continuing care (CHC) and NHS funded Nursing 16 Care 9.9 Fast Track Pathway for Continuing Healthcare Mental Capacity and Independent Mental Capacity 17 Advocates Patient Advocacy and Voluntary Arrangements Carers Delayed transfer of care ( delayed discharge ) Specific arrangements for Discharge Documents to accompany the patient on discharge Patients taking their own discharge against medical advice Discharge/transfer to a care Home (New) or up-rating from 21 Residential to Nursing Home 10.4 Out of Hours Discharge Out of Hours Self Discharge Patients refusing to be discharged Discharge of Day Case Patients Discharge of Emergency Department Patients - including 2530 homeless, end of life, asylum, learning difficulties 11.1 Transfers to specific Locations 30 June 2015 Page 2 of 44

3 Paragraph Title Page 12. Internal NUH Patient transfers Training/Awareness Implementation and Monitoring Equality and Diversity Statement Equality Impact Assessment Statement Here for You References and related policies and procedures 35 Appendix 1 Glossary of Terms 36 Appendix 2 Equality Impact Assessment 37 Appendix 3 Environmental Assessment 39 Appendix 4 We are Here For You 41 Appendix 4 Policy Implementation Plan 42 Appendix 5 Certification of Employee Awareness. 43 June 2015 Page 3 of 44

4 1. Introduction 1.1 At NUH we believe that patients should be looked after and treated in a setting which is appropriate to their needs and, as far as practicable, meets their preferences. 1.2 This policy describes best practice guidelines for all NUH staff who are transferring a patient from NUH care (discharge to home or transfer to another care provider). There is a separate Policy for internal NUH transfers. 1.3 Patients and their carers should receive person-centred transfers of care which respect them as individuals and recognise both their individual needs and personal preferences. This requires clinicians and managers to: ensure that patients and their carer(s) are listened to and engaged in care-planning decisions enable patients to make informed choices, and be involved in all decisions about their needs and support involve and support carers whenever necessary respect patients dignity and privacy and recognise individual differences and specific needs including those arising from cultural and religious differences provide co-ordinated and integrated responses to patient needs needs and to enquiries about care Each transfer (discharge) needs to be safe, effective and caring. It should also be efficient to ensure that each patient receives the right care, in the right place, at the right time. This policy complies with relevant Department of Health policy and guidance, National Health Service Litigation Authority (NHSLA) standards, local standards and local joint agreements, for all in-patients. 2 Background 2.1 NHS organisations and Local Authorities (Social Service functions) are required to comply with the regulations and obligations created by the Community Care (Delayed Discharges etc) Act The Act places duties on NHS bodies and Local Authorities in England to communicate with each other and with patients and carers about the discharge of a June 2015 Page 4 of 44

5 patient from hospital. The NHS is required to notify the relevant Local Authority (council) of a patient s likely need for community care services, and of his/her proposed discharge date. 2.2 Continuing Health Care 2009 NHS Continuing Healthcare (CHC) describes an adults (aged 18 or over) entitlement to care that meets physical or mental health needs that (1) have arisen as a result of disability, accident or illness and (2) meet local Eligibility Criteria. Broadly, to meet the criteria for NHS continuing care an individual s needs must be intense, complex, unpredictable, unstable and deteriorating. If a multi-disciplinary assessment suggests that a patient may meet these criteria, referral is made to a team of assessors. They will carry out their assessment of need against the eligibility criteria. The NHS is responsible for arranging and funding NHS CHC services for eligible patients who are in a hospital, a care home, or their own home. 3 Policy Scope 3.1 This Policy applies to all patients being discharged from inpatient care in NUH, regardless of age or diagnosis. This Policy should be read in conjunction with the Trust s Safeguarding for Adults and Children (including those in need of protection) Policies. 3.2 This Policy applies to all transfers/discharges from hospital, including out-of-hours discharge, external transfer, and end-of-life care discharge. 3.3 Carers are people who care, unpaid, for friends or family members who are ill, frail or disabled (NUH Carers Policy May 2014). Under the care Act 2014 a carer is someone who helps another person, usually a relative or friend, in their day-to-day life. This is not the same as someone who provides care professionally, or through a voluntary organisation. 4 Policy Statement 4.1 The Trust is committed to ensuring that each patient is safely and effectively discharged or transferred. The Trust will, so far as is reasonably practicable, seek to ensure that; June 2015 Page 5 of 44

6 All patients experience well-organised, safe and timely assessment and discharge from hospital (unnecessary delays in transfer of care or discharge will be minimized). Each patient, and where appropriate their carer and family, is prepared, physically and psychologically, for transfer home or to an agreed alternative environment. There is effective and timely consultation with patients and their families and/or carers in planning and managing the transfer/discharge process. Patients and their families and/or carers are supported and assisted throughout the process. There is effective communication between hospital and community multi-disciplinary/multi-agency teams. Sharing of patient information must adhere to the principles of confidentiality and consent. Appropriate documentation accompanies the patient on transfer /discharge. 4.2 Patients do not have the right to choose a non-available transfer location, to insist on the provision of informal care, or to remain in hospital when there is no clinical need. 4.3 Patients with mental capacity for the decision have the right to make what others regard as unwise or risky decisions about transfer location. 5 Principles 5.1 Discussion about transfer should start early (if possible before admission) to anticipate problems, plan for transfer and agree an expected transfer date and location. 5.2 A person-centred approach which treats individuals with dignity, respect and fairness, and meets their diverse and unique needs should be maintained. 5.3 The patient (or their carer if appropriate) should be at the centre of any decision-making and should be consulted (including about their choices) at all stages of the process. 5.4 Patients should be provided with good information to enable them to make care-planning choices. June 2015 Page 6 of 44

7 5.4 Transferring / discharging staff should maintain an awareness of an individual s gender, religion, sexual orientation, race, ethnicity, disability, age and culture throughout the discharge process, and consider implications for discharge that may arise due to these characteristic. 5.5 Where patients agree, relatives and carers should be included in assessment, planning and implementation transfer/discharge. 5.6 Where patients do not wish other individuals or agencies to become involved, NUH staff (and staff of other agencies working with NUH patients) should respect those wishes, except where there are compelling grounds for believing that the patient lacks the necessary competence/ capacity to give (or withhold) consent for the proposed action (e.g. inter-agency referral, discussion or intervention). [See Consent to Examination or Treatment Policy]. Competent patients have freedom to choose their discharge destination and care [see Mental Capacity Act Policy and the Consent to Examination or Treatment Policy]. 5.7 Competent patients have the right to choose their discharge destination and care [see Mental Capacity Act Policy and the Consent to Examination or Treatment Policy]. Relatives/carers do not have the right to overrule a competent patient s choice. ] 5.8 The rights of patients who do not have capacity to make decisions about transfers must be protected, as enshrined in the Mental Capacity Act There should be effective communication between practitioners, patients and carers through planning and enacting the transfer Planning for complex transfers should be multidisciplinary, based on collaborative multi-professional and multi-agency working, one feature of which is agreement about who is responsible for specific actions and decisions on the process and timing of transfers Social services should be involved where appropriate, and agreed standards for timely assessment and notification(s) by NUH should be met Most carers have a legal right to an assessment of their own needs (by the relevant local authority) to support them in their caring role (separate to the assessment of the patient s needs). June 2015 Page 7 of 44

8 5.13 Eligibility for NHS continuing health care should be described, and considered where appropriate. 6. Enacting the Principles (Actions for NUH staff) 6.1 Transfer / discharge is an active process. Safe transfer / discharge requires that hazards of the process to patients are identified and controlled (risk assessment and mitigation). This is particularly important for the discharge of patients who have complex needs. The current NUH Transfer of Care/Discharge Pathway is attached [Appendix 1]. 6.2 Transfer/discharge plans and discussions of each patient should be recorded clearly in the medical and/or nursing notes. These plans should be reviewed daily. 6.3 Start planning for transfer at or before admission. 6.4 Identify whether the patient has simple or complex transfer needs, and involve the patient and carer in that decision. 6.5 Develop a clinical management plan for every patient within 24 hours of admission, and expected date of transfer within 48 hours. 6.6 Identify to patients and carers/relatives a Predicted Date of Medically Safe for Transfer (PDMST) as soon as possible after admission. 6.7 Coordinate the transfer of care process through effective leadership and handover of responsibilities at ward level. 6.8 Review the clinical management plan with the patient each day, take any necessary action, and update progress towards the transfer date. 6.9 Ensure timely referrals for necessary / appropriate specialist advice or services and be clear about the impact of the referral on the transfer/discharge process. This includes withdrawing notifications when circumstances have changed Involve the patient and carer(s) so they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence Consult with the patient, and their carer, prior to a referral to a community service for assessment.. June 2015 Page 8 of 44

9 6.12 Plan transfers to take place on each of the seven days Plan transfers to be as early in the day as practicable Use a checklist hours before transfer; this should include a plan for post-transfer clinical care Make decisions about transfers each day (7/7) Ensure effective and timely communication/handover with all relevant agencies Ensure that appropriate documentation is available for each patient at the time of their transfer/discharge Ensure that completion of a patient s discharge documentation (including prescription, TTO (Tablets to Take Out) does not introduce unnecessary delays in the patient s transfer/discharge NUH will ensure that dispensing a patient s discharge medications does not introduce unnecessary delays in the patient s transfer/discharge. 7 Key Responsibilities 7.1 The Chief Nurse has overall responsibility for ensuring that there is an appropriate NUH policy, and that effective systems and processes in place to underpin the safe discharge or external transfer of patients. 7.2 The Medical Director is responsible for ensuring that effective systems and processes are in place to allow Medical Staff to transfer/ discharge patients. 7.3 Clinical Directors will ensure that this Policy is implemented and monitored, and will investigate non-compliance and implement actions to maintain or improve compliance. 7.4 The Responsible Consultant (Midwife for women admitted for Midwifery-Led care) is accountable for all medical aspects of the patient s pathway (including the discharge or transfer of care). S/he may delegate this responsibility to competent medical staff or to nursing/ midwifery staff who have been assessed as competent to carry out Nurse / Midwife Facilitated Discharge (NFD). June 2015 Page 9 of 44

10 7.5 Heads of Service are responsible for ensuring that there is a process for daily review by a senior clinician to identify those patients who are ready for transfer/discharge (and that this is documented), and compliance with that process. 7.6 The Consultant (or senior decision-maker to whom they have delegated) undertaking the daily review (7.5) is responsible for identifying (or reviewing) a Predicted Date of Medically Safe for Transfer (PDMST) on each patient during the daily review, and that this is recorded on Medway PAS. 7.7 The Responsible Consultant is responsible for ensuring that: Patients who are potentially ready for discharge should be reviewed as early in the day as is consistent with clinical priorities (i.e. at the beginning of ward-rounds whenever practicable) Patients approaching the last days or weeks of life are considered for the fast-track discharge process (and where appropriate the fast track checklist should be completed) Referrals to other specialist teams or services necessary to formulate comprehensive diagnostic, treatment (including rehabilitation) and transfer discharge plans are made without unnecessary delay Prescriptions for discharge are written at soon as is safe and practicable. Where there is less than 24 hours notice of transfer/discharge, the prescription should be completed as soon as practicable after the decision to transfer/discharge. For ettos this will mean that it is at a Stage 2 by on the day prior to transfer Appropriate and adequate written information (TTO/ etto; electronic Tablets to Take Out) is available for dispatch to the GP at the time of discharge Where the patient is discharged to a residential or nursing home a copy of the discharge summary is sent to the Medical Officer at the home s address For patients not registered with a GP, advice is taken from the Supported Transfer of Care Team or CCG For children and young people the Health Visitor is informed, and for babies the Community Midwife. 7.8 The Site Matron will: Monitor bed pressures on an hour-by-hour basis, and escalate actions and contingencies (including those around discharge) as required, and according to NUH procedures (including informing Silver On-call ) Attend escalation meetings in response to bed pressures June 2015 Page 10 of 44

11 7.9 Matrons will: Ensure implementation of systems to support this policy in their area of responsibility (including for outlying patients), which they will keep under regular review Take appropriate action when delays in patient pathways occur Attend regular Trust-wide discharge meetings, or send a deputy 7.10 Ward Sisters/Charge Nurses/Team leaders will Ensure that all staff are aware of and comply with the NUH Transfer of Care/Discharge Pathway, and this policy and monitor standards and work with managers and staff to ensure compliance. Ensure that an effective discharge planning process operates in the ward. Ensure any delayed discharges are escalated appropriately, and in a timely way. Attend regular bed meetings or send a deputy (who may be the discharge coordinator). At the meeting they will identify the number of predicted discharges and any issues which are impacting on effective discharge from their ward /clinical area Ensure that the bed management system and other hospital IT systems are updated in as real time as possible 7.11 Registered Nurses, Midwives, Practitioners and Allied Health professionals will Ensure that they can demonstrate the appropriate skills and knowledge needed to enable them to provide the necessary standard of care in the assessment of a patient requiring discharge and determine the appropriate level of risk and discharge care requirements. Ensure that patients, carers and members of the MDT are fully involved at all stages of the admission/discharge process 7.12 Discharge Coordinators will Ensure that ward discharge processes follow the NUH Transfer of Care Pathway. Ensure that patients, carers and members of the MDT are fully involved at all stages of the admission/discharge process June 2015 Page 11 of 44

12 Help ward staff to improve discharge by optimising the use of IT and information, and updating hospital systems in as real time as possible. Attend regular Trust-wide discharge meetings (at request of ward manager). At the meeting identify the number of predicted discharge Inform the ward manager of any issues that are impacting on effective discharge from their ward 7.13 The Supported Transfer of Care Team (STOC) will: Support staff in discharge or transfer of adult patients Advise and help train staff about the discharge planning process Advise on complex discharge and continuing health care needs Assess patients for suitability for short/long term rehabilitation Attend regular Trust-wide discharge meetings Inform their line manager of any issues that are impacting on effective discharge processes Record data relating to the STOC transfer process 7.12 Pharmacists will: Ensure that Tablets to Take Out (TTOs) are checked and dispensed in a timely manner Pre-transcribe TTOs into the e TTO system, whenever possible. Ensure that the final check box on the discharge prescription is signed off indicating that the checking of medications is complete. Advise patients and staff relating to discharge medication Attend regular Trust-wide discharge meetings Inform their line manager of any issues that are impacting on effective discharge processes 7.13 The Hospital Palliative Care Team will provide advice and support for the transfer of complex end of life and palliative care patients. 8. Nurse facilitated discharge (NFD) 8.1 The need for nurses and midwives to be able to discharge patients was identified in the NHS plan (DoH July 2000). Legal responsibility for a patient s care remains with the Responsible Consultant (or Named Midwife in maternity services) during a patient s admission, stay and discharge. June 2015 Page 12 of 44

13 8.2 Nurse-facilitated discharge is in place in certain areas of the trust. Staff may carry out nurse-facilitated discharge provided they have been assessed as being competent, and there is an agreed local NFD procedure. 8.3 If a patient meets the criteria for nurse-facilitated discharge then the agreed proforma for that speciality must be used, in conjunction with the approved documentation to ensure a safe and effective discharge. June 2015 Page 13 of 44

14 9 Common arrangements for Discharge and Transfer 9.1 Transport The presumption is that patients will make their own arrangements for transport home. This should be by relatives, friends, public transport or taxis (not paid for by the Trust) [but see section 9.7 for Day Case Patients] The patient should be asked to make arrangements to leave hospital as early in the day of discharge as is reasonably practicable. For discharges confirmed the previous day this should typically be before 10am The discharging professional must consider if any equipment and / or consumables need to be sent with the patient. Suitable arrangements must be in place with regard to equipment as per NUH policy The discharging professional must ensure the patients belongings (including house keys), valuables, medications, and documentation are returned to the patient Where a patient has no means of transport, or requires an ambulance on clinical grounds, arrangements can be made via the Patient Transport / Ambulance Service at least one day in advance of discharge where possible [please refer to the Patient Transport Policy for further details and instructions]. When arranging transport for discharge the requesting staff must confirm and check the discharge address (it may differ to the patient s home address). The discharging professional must ensure that if the patient is not for attempted resuscitation this is communicated to the transport crew. A completed Do Not Attempt Resuscitation (DNAR) form must accompany the patient When discharging bariatric patients via the ambulance service a bariatric discharge assessment document must be completed - this can be found in the Bariatric / Heavy patient manual handling procedure document 9.2 Dressings / Care Products Patients requiring wound management or continence products (i.e. catheters, catheter bags, sheaths), should be given sufficient quantity to take home. This should be for 7days, some may need to be June 2015 Page 14 of 44

15 prescribed as take home medication (TTO). A referral to relevant district nursing services should be made in advance of discharge whenever practicable so that the community team are fully aware of the patient s needs for a continuing supply of consumables and potentially specialist team involvement. If the patient has a cavity / open wound that has dressings/ retained gauze/ topical negative pressure therapy (VAC) the wound management discharge plan document must be completed in addition to the nursing discharge summary. This will allow for clear communication and ongoing management of the wound in the community Non-prescribable items such as pads and pants should also be provided to the patient (sufficient for 7 days), and the District/Community Nurse informed (they will provide further supplies). For school-age children further supplies will be provided by their school nurse. In providing the supply of 7 days duration staff should take into account prescribing and supply restrictions that may apply for some products in the community If staff are uncertain they should contact the District/Community nurse to clarify dressings supply, or the Continence Advisory Service based at Sherwood Rise Health Centre for continence products. 9.3 Supply of medicines at discharge NUH will ensure that the minimum supply at discharge will be days appropriate to the needs of the individual or unless cited differently in the exclusion list (see pharmacy prescribing guidelines) e.g. when patient has own supply or a further supply at home or has a repeat prescription ready to be collected by the patient and this can be achieved before the patient s medicines run out Where it is verified that the patient has a minimum of days of medicines at home, further medicines (including analgesic medication) will not be supplied. Any new or changed items will be issued if appropriate as above. 9.4 Equipment to take out Arrangements should be made prior to discharge for: any equipment considered essential for discharge ( equipment is not routinely loaned out). any essential equipment/alterations to be delivered and installed in the patient s home. instructions for use should be given to patient and relative. June 2015 Page 15 of 44

16 any necessary training for patient/carer should be arranged and contact numbers provided. An end user form should be completed for patients who are discharged with a medical device If the patient requires ONLY nursing equipment (e.g. bed, mattress, bed pans etc) and does not require specialist OT equipment (e.g. hoist, chair raisers, raised toilet seat), then the Ward Nurse should order the (nursing) equipment from British Red Cross. A PIN number is required to order equipment from the British Red Cross this can be obtained by the Ward Sister/Charge Nurse from the British Red Cross Society on Staff should complete a British Red Cross request form, regardless of whether the equipment is going with the patient or being delivered directly to the patient s home Sticks Crutches and Frames If a patient is being discharged with (e.g.) crutches or a frame as advised by a physiotherapist a British Red Cross order should be completed. If the patient is using hospital transport the equipment must be booked onto the transport Wheelchairs and Prostheses For assessment and provision of wheelchairs or specialist prosthetic services the therapist (usually the Physiotherapist or Occupational Therapist) should contact the Nottingham Mobility Centre, City Campus Tissue Viability and Pressure Relieving Equipment Please consult information sheets or contact the Tissue Viability Service Occupational Therapy equipment If items such as hoists, chair raises or raised toilet seats (or home alterations) are required ward staff should refer the patient ASAP to Occupational Therapy (OT)) for assessment. OTs can order such equipment from British Red Cross. Independent advice and demonstration for patients, carers and staff requiring information about disability equipment can be obtained from The Disability Living Centre, Middleton Court, Glaisdale Parkway off Glaisdale Drive West, Bilborough, Nottingham, NG8 4GP Tel June 2015 Page 16 of 44

17 9.5 Medical Certificates Medical certificates are issued to inpatients on request to cover the period of time they are in hospital A Med 10 certificate (yellow) is issued by a registered nurse or a doctor and covers only the duration of the inpatient episode From April 2010 the statement of a fitness to work has replaced Med 3 and Med 5; it allows the doctor 2 options; Not fit for work or should refrain from work for a given period. May be fit for work (where the doctor s assessment is that the patient s health condition does not necessarily mean that they are not fit to return to work). 9.6 Medical device removal (e.g. cannulae) All patients leaving the hospital must have all medical devices which are no longer required removed (e.g. cannulae). If a patient is discharged and a medical device is mistakenly not removed, the patient should be contacted and asked to return to the discharging ward for its removal. This is the responsibility of the discharging nurse or of whoever identifies that the device has not been removed. Appropriate documentation recording the incident should be completed according to the NUH Incident reporting policy and procedures If a patient leaves the ward without being discharged with a device still in situ it is the Trust s it is the responsibility of the nurse in charge to ensure that the patient is asked to return to the hospital or visit their GP for removal. It may be appropriate to report the patient as vulnerable or missing to the police if the patient cannot be readily contacted. 9.7 Specialist Nurse Involvement Where a specialist nurse has been involved in inpatient care, the discharging nurse should ensure the specialist is aware when discharge is being arranged (to enable any necessary follow up requirements to be organised). However a patient s discharge should not be delayed if the Specialist Nurse cannot be contacted, as long as they are informed at the earliest opportunity. 9.8 Outpatient Appointments June 2015 Page 17 of 44

18 9.8.1 When a patient requires outpatient follow-up please refer to the NUH Out Patients policy. Wherever appropriate the appointment should be made before discharge When an outpatient appointment is required after an inpatient stay the ward receptionist should make the appointment with the patient before they leave the ward The following information is required to book an OP appointment: Whose Clinic, i.e. Consultant s Name Specialty Clinic, if appropriate When for, i.e. number of weeks away Patient s name and hospital number Transport should NOT routinely be arranged for outpatient appointments. If transport is going to be needed on clinical grounds the patient should be given the Transport Booking Office number Emergency Department (ED) staff will arrange for ED patients requiring an OP appointment to attend fracture clinic, ED clinic or Ear, Nose and Throat (ENT). 9.9 NHS Continuing Healthcare Care (CHC) and NHS Funded Nursing Care (FNC) The NHS Continuing Healthcare Checklist (CHC) is a screening tool to help practitioners assess whether a patient s needs might be of a level or type that they may be entitled to NHS CHC. Patients and their carers should be consulted that an assessment for continuing care is taking place, and should be helped to participate in the process taking into consideration communication and language needs. If the checklist suggests there is a possibility that the patient is eligible for NHS CHC, the practitioner should arrange for a multi-disciplinary team member to carry out a needs assessment The patient and relatives should be informed that NHS continuing healthcare (CHC) is fully funded by the NHS, but it cannot be assumed that this is for life. Funding is subject to regular review (at least annually), when the person s healthcare needs are re-assessed The eligibility for NHS funded health care is based on the person s needs, and the nature, complexity, predictability and intensity of these needs, and not on the medical diagnosis. June 2015 Page 18 of 44

19 9.9.4 Patients and their family must be informed if they are not eligible for NHS continuing funded healthcare, and that they may have to pay for necessary social care either at home or in a nursing home pending the outcome of a financial assessment carried out by their local authority (social services) A patient s care may be funded fully or in part by the relevant local authority if their financial position is below the threshold set by the relevant local authority Some patients who are not eligible for NHS CHC will be eligible for NHS funded nursing care if they are assessed as requiring accommodation in a care home with nursing. An assessment is required and referral for this is made as one of the choices on the checklist Fast Track Pathway for End of Life Care Patients The fast track process facilitates rapid transfer/discharge for those patients in the last days of life who wish to be cared for at home or in a nursing home by providing funding for a higher level of care. Following referral the fast track Co-Ordinator will assess care needs and/ coordinate end-of-life care at home or identify a suitable palliative care nursing home bed. For children the Community Matron will generate this End of Life Care package The fast track documentation, a brief guide and discharge checklist are available via the palliative care intranet page A patient in the last days of life can also choose to remain in hospital, and in this instance only the fast track form needs to be completed Mental Capacity and Independent Mental Capacity Advocates All professionals working with adults in health care must be aware of their duties under the Mental Capacity Act where there are any concerns that a patient may not be fully able to participate in discharge planning for reasons of mental incapacity. Readers are referred to the NUH Mental Capacity Act Policy, and the NUH Safeguarding Vulnerable Adults intranet website, which includes the Mental Capacity Act Code of practice (where these duties are described in detail, please refer to section 5.23) If a patient is judged not to have capacity to make a decision about their place of transfer /discharge (capacity is decision-specific) then the June 2015 Page 19 of 44

20 decision-maker will be the allocated social worker. A best interests decision will need to be made after consultation with health professionals, family member(s) or carers (not statutory services), or a friend Where there are no relatives, carers or friends available to consult about the best interests of a patient who lacks capacity, the Mental Capacity Act places a legal duty on the NHS (and Local Authority) to refer patients to an Independent Mental Capacity Advocate (IMCA). The IMCA supports people who lack capacity to make important decisions (e.g. serious medical treatment and long term placements (more than one month). The IMCA service in Nottingham (City and County) is provided by; Pohwer Icon business Centre Lake view drive Sherwood Park Nottingham NG15 0DT Pohwer have provided a national IMCA hotline for information and referrals: Tel: Fax: IMCA@pohwer.net Children and Young People under the age of 18 (See Safeguarding Children (including those in need of protection) Policy). If there are concerns about the emotional or psychological well-being of a child or young person, a CAMHS (Child and Adolescent Mental Health Services) referral should be made. Contact Patients Advocacy and Voluntary Arrangements Information is available on every ward/unit detailing advocacy schemes and services for patients, and carer support from other agencies Carers often have knowledge, expertise and experience of caring for the patient prior to admission. The importance of their role should be acknowledged. Their early engagement can avoid delays in the discharge. Carers should be kept informed and involved in all stages of the discharge process If there is a carer involved, they can be offered (and have a right to receive) a separate assessment of their own needs by Social Services. June 2015 Page 20 of 44

21 This should be a genuinely separate assessment to consider their need for support, especially if they have not previously identified themselves as a carer In planning discharge it should be recognised that carers have a choice about whether to continue to be a carer Consideration should be given in discharge planning to scheduled or unscheduled short term/respite caring breaks Special care should be taken to consider the individual needs of young carers and carers who may themselves be vulnerable [see Safeguarding Children & Young People and Safeguarding Vulnerable Adult Policies] Delayed transfer of care ( delayed discharge ) The Trust records delayed discharges/transfers The definition of DTOC is that the patient s clinical condition is such that ongoing assessment, treatment, rehabilitation and / or recuperation does not require acute hospital facilities. It can continue in a less acute environment, such as an assessment or rehabilitation facility or in the patient s home. This should be confirmed by a senior clinician (usually the Consultant in consultation with the ward MDT) Any queries regarding the reporting of Delayed Discharges/Transfers of Care should be directed to STOC. 10. Specific arrangements for Discharge (Refer to Appendix 1) 10.1 Documentation to accompany the patient on Discharge It is essential that patients are discharged with sufficient information about their treatment to ensure continuity of future care. See section 10.3 of this Policy for specific arrangements with local Healthcare June 2015 Page 21 of 44

22 providers. In all other cases the following items should be provided at discharge; A discharge pack A doctors discharge sheet which includes an immediate admission summary and medication changes A copy of the Nursing /Midwifery discharge summary Appointment card for next Outpatient visit or admission (if arranged prior to discharge) Discharge leaflet and if applicable an advice leaflet from the MDT Feedback form 10.2 Patients taking their own discharge against medical advice A patient with capacity cannot be detained in hospital against their wishes except (1) under the provisions of the Mental Health Act or (2) under the common law in extreme cases where their or another s safety is immediately threatened Where mental capacity is in doubt, patients should be assessed in accordance with guidance given in Appendix 3 of the Trust s Mental Capacity Act 2005 Policy (two stage test). If there is a clear need to detain in hospital a patient who lacks capacity the provisions of the Mental Capacity Act should be used. However, if the detention is likely to be ongoing, or the patient is making repeated requests to leave the clinical area, then a Deprivation of Liberty authorisation needs to be considered When a patient is determined to discharge himself or herself from Hospital against medical advice the ward nurse should try to persuade the patient to stay and summon a doctor, who should likewise seek to persuade the patient to stay It may be helpful to engage the help of relatives in efforts to persuade a patient to stay If the patient cannot be persuaded to remain in hospital they should be asked to sign a 'Self Discharge from Hospital' form or to sign in the medical record to indicate that they are discharging themselves against medical advice (copies should be forwarded to the Directorate Manager and filed in the patient s medical record). June 2015 Page 22 of 44

23 If the patient refuses to sign the form the nurse and/or doctor involved MUST document this in the patient s notes. The medical staff should document 'own discharge' in the medical record and inform the patient s G.P with a degree of urgency commensurate with the patient s clinical problems and condition The registered ward nurse / midwife should inform the next of kin and community services where appropriate An incident form may be completed at the discretion of the nurse in charge of the ward or the doctor If a patient registers at the Emergency Department but does not wait for treatment, or discharges themselves from ED against medical advice following assessment or treatment, a record should be completed and filed in the patient notes. Where applicable, the Emergency Department Missing Persons policy should be followed In the case of parents or guardians taking their child home against medical advice the nurse should try to persuade the patient (and parent / guardian) to stay and summon a doctor, who should likewise seek to persuade the patient to stay. Staff should comply with the Safeguarding Children (including those in need of protection) Policy and follow the Local Safeguarding Board Interagency Guidance, consulting with the Safeguarding Children team and social services if appropriate Discharge / transfer to a Care Home (new) or up-rating from Residential to Nursing Home STOC will be involved in many such discharges/transfers and is readily available for advice Before transfer to a Residential or Nursing Home a patient and carer should have been consulted with prior to the ward sending a referral for a health and social care assessment, and consideration given on the eligibility for fully funded continuing healthcare. These actions are documented on NOTIS Where the patient is assessed by social care as self-funding, they should not be discharged prior to their assessment for eligibility for fully funded continuing healthcare. June 2015 Page 23 of 44

24 A patient should not be transferred until authority has been given by Social Care (or by a representative of the CCG in the case of fully funded continuing healthcare) The patient should be offered, jointly with Social services an Interim Care placement if they are medically safe to be discharged but a place, appropriate care, or funding is not available (or has not been identified) within a reasonable time. A reasonable time depends on the amount and complexity of what is required to be put in place Once placement has been arranged and funding confirmed the principles of the Discharge Planning Process described in this policy should be applied Where the patient is assessed as self-funding for their placement, it is vital that good communication is maintained with the persons responsible for arranging placement, to ensure that the arrangements are made in a timely manner It is essential that good communication be maintained between the discharging ward and the receiving care or nursing home to ensure continuity of care. A Patient Care Plan should be completed with all the relevant details and one copy sent with the patient on discharge Out of Hours Discharge This policy seeks to ensure that all patients, including those with complex needs, are discharged safely with a planned, timely and appropriate care package Patients, especially those who need a supported, non-urgent transfer, should generally not be transferred (discharged) from NUH wards between the hours and 07.00, unless agreed by the patient (and where relevant carer) and the relevant site (campus) matron Patients may leave the Emergency Department and Assessment Units, and the Maternity Unit, at any time If clinical need requires transfer (discharge) outside normal working hours (ie between 2200 and 0700), staff should discuss and agree the transfer arrangements with a senior member of staff (Site Matron, Matron or Consultant). If necessary the Site Matron will act as the link with EMAS to authorise the use of ambulance transport. June 2015 Page 24 of 44

25 For out-of-hours transfers NUH staff must inform the receiving hospital or care home that the patient is being transferred. NUH medical staff must ensure that appropriate information is relayed to the receiving clinical team (typically the GP) with a degree of urgency commensurate with the clinical condition of the patient Where discharging staff have concerns about the safety or effectiveness or appropriateness of a discharge plan they should discuss these with a senior member of staff (Ward Sister/Charge Nurse, Matron, Duty Nurse Manager or Consultant) Out of Hours Self-Discharge Where a patient with mental capacity chooses to take their own discharge against medical advice, primary care services should be alerted with a degree of urgency commensurate with the clinical circumstances. It may be appropriate to contact the primary care emergency services (this should be by medical staff). More usually the patients GP (in maternity cases the community midwife) should be contacted the following day Patient refusing to be discharged A patient does not have the right to occupy an NHS bed indefinitely If a patient who is clinically ready for transfer and who has been offered a reasonable option for transfer refuses to be discharged, and they are not eligible for a review of their case under the Continuing Health & Social Care criteria, staff should consider escalation on a case-by-case basis according to the NUH Leaving Hospital Policy The content and outcome of discussions with the patient and others must be recorded in both the medical and nursing notes If necessary, legal advice is available via the Trust Secretary 10.7 Discharge of Day Case Patients Before a day case patient is discharged from the Day Surgery Unit, they must be clinically stable and safe to leave. They should be discharged as per the day surgery discharge criteria. In addition, the June 2015 Page 25 of 44

26 discharging nurse must ensure that the following information has been obtained at pre-assessment or been clarified during the admission: There is someone to collect the patient in their own transport or willing to escort the patient in a taxi There is a responsible and physically fit person to look after the patient for the first 24 hours after their operation Documentation is competed as per Discharge of Emergency Department Patients Before any patient is discharged it is vital that arrangements are made to ensure a smooth transition from care in the Emergency Department to care in the community. A well organised plan should be prepared and agreed for each individual patient prior to discharge Once it has been agreed that the patient is medically fit for discharge, the following should be considered: Assessment of mobility Assessment of whether discharge can be made to a safe and suitable home environment. Special care is available if required, for the frail, confused or disabled patients living alone. Following consultation with the patient and their carer, a referral to STOC should be arranged if the patient consents. If the patient does not consent, then nursing staff can make a best interest referral if the patient is deemed to lack capacity, and should document this is the patient records. The NUH Care Act guidance will outline actions to be taken in the event of a refusal to be referred to another service. If a patient is referred to STOC while in the department it is the responsibility of the ED nurse to inform the receiving ward of the referral and to document this in the notes Child Protection issues should be dealt with as per the NUH Safeguarding Children (including those in need of protection) Policy Domestic violence issues should be dealt with as per the NUH Domestic Violence policy Vulnerable adults should be dealt with as per the NUH Safeguarding Vulnerable Adults Policy. Patients requiring assessment under the June 2015 Page 26 of 44

27 Mental Health Act or patients who have self-harmed should be referred directly to the Department of Psychological Medicine (DPM) team Patients presenting with drug- or alcohol-related problems can be referred to the Alcohol Liaison Nurse or to their GP Transport as per NUH transport policy [& see Section.1] Items to take Home. In addition to patient's property, consideration must be given to the following: Medicines/drugs are dispensed from pharmacy. After 1800hrs TTO s can be dispensed by ED nursing staff. Payment for prescriptions should be made via the pay machine in ED reception. Proof of entitlement to free prescriptions must be shown. Additional dressings are not provided. Patients should be given advice to attend their GP for necessary wound checks and dressing changes. GP letters must be sent within 24 hours of discharge. Information. All patients and carers should be given full information about arrangements for ongoing treatment and social care, including who to contact in the event of an emergency / relapse. All patients should be given the relevant advice cards on discharge. Where appropriate information should be given regarding how to contact the relevant Self-Help Group Patients who are homeless, or live in hostel accommodation, or live in poor housing Specific discharge plans should be considered for those persons who declare at admission that they are of no fixed abode (NFA). It is best if the patient can go to stay with a friend or relative when ready for discharge, even as a temporary measure. This possibility should be explored as soon after admission as possible and the patient should be encouraged and helped to help to identify an appropriate discharge destination. If a patient has no friend or relative to go to stay with, please contact STOC. Wherever possible we should not discharge vulnerable homeless patients to the streets after a hospital admission or ED attendance. The clinical team should explore eligibility for social care input. June 2015 Page 27 of 44

28 If you assess the patient as being vulnerable and homeless then a referral to Adult Social Care should be made to assess eligibility for short term care. If you do not consider the patient vulnerable and they do not require assessment by Adult Social care you should direct them to contact Housing Aid either in person or by telephone. Housing Aid 135 Lower Parliament Street Nottingham NG1 1EE Opening hours: Monday- Friday ( Wednesday) Telephone (this number also takes calls out of hours) NUH recognise that individuals have the right to decide for themselves if they wish to follow the advice given to them, and provided they do not lack capacity, they may choose to refuse any offer of support. Alternative sources of help for the homeless: Framework Central Access Point- this provides an effective referral service for applications to floating support and accommodation services in Nottingham City and Nottinghamshire. Patients can self refer or can be referred on behalf of a support agency. Telephone: or by texting Street Outreach- this service has two main roles; to engage with and help rough sleepers and to quantify the extent of street homelessness in partnership with other agencies. Street outreach actively looks for rough sleepers and works in the early hours of the morning. This team can be contacted on: Homeless Health Team- this team is based at the Health Shop and is made up of three specialist nurses. They offer Health Advice, health promotion, dressings and wound care, nurse prescribing, triage and treatment for minor health conditions and injuries, run drop in clinics, liaison and referral to other services. Telephone: The clinics are held as follows: Clinic Times Monday am London Road Service GP/Nurse clinic am Emmanuel House Day Centre (Drop In) am Friary Day Centre (Drop In) pm The Health Shop (Drop In) Tuesday June 2015 Page 28 of 44